Associations between HIV stigma and health-related quality-of-life among people living with HIV: cross-sectional analysis of data from HPTN 071 (PopART)

People living with HIV (PLHIV) report lower health-related quality-of-life (HRQoL) than HIV-negative people. HIV stigma may contribute to this. We explored the association between HIV stigma and HRQoL among PLHIV. We used cross-sectional data from 3991 randomly selected PLHIV who were surveyed in 2017–2018 for HPTN 071 (PopART), a cluster randomised trial in Zambia and South Africa. Participants were 18–44 years, had laboratory-confirmed HIV infection, and knew their status. HRQoL was measured using the EuroQol-5-dimensions-5-levels (EQ-5D-5L) questionnaire. Stigma outcomes included: internalised stigma, stigma experienced in the community, and stigma experienced in healthcare settings. Associations were examined using logistic regression. Participants who had experienced community stigma (n = 693/3991) had higher odds of reporting problems in at least one HRQoL domain, compared to those who had not (adjusted odds ratio, aOR: 1.51, 95% confidence interval, 95% Cl: 1.16–1.98, p = 0.002). Having experienced internalised stigma was also associated with reporting problems in at least one HRQoL domain (n = 552/3991, aOR: 1.98, 95% CI: 1.54–2.54, p < 0.001). However, having experienced stigma in a healthcare setting was less common (n = 158/3991) and not associated with HRQoL (aOR: 1.04, 95% CI: 0.68–1.58, p = 0.850). A stronger focus on interventions for internalised stigma and stigma experienced in the community is required.


S1a: Trial design
The HPTN 071 (PopART) trial was completed between 2013 and 2018, in 21 large, urban communities in Zambia (n=12) and South Africa (n=9).In total, the communities had a population of approximately 1 million people and each community was the catchment population for a government clinic.
At the start of the trial, the communities were split into seven triplets, matched on location and estimated HIV prevalence.The three communities in each triplet were then randomly assigned to three trial arms (two intervention arms and a control arm), using restricted randomisation to ensure balance across the trial arms with respect to population size, baseline ART coverage (the percentage of people living with HIV who were receiving ART), and HIV prevalence.Arm A communities received a combination prevention intervention with universal ART.Arm B communities received a combination prevention intervention with ART provided according to local guidelines.Arm C communities did not receive a combination prevention intervention but received standard care at government clinics, including HIV testing and ART offered according to local guidelines.The combination prevention intervention included, amongst other components, home-based HIV counselling and testing delivered by community HIV care provider teams, who also supported linkage to HIV care, encouraged ART adherence, provided condoms, and promoted a package of prevention strategies among HIV-negative individuals, including voluntary medical male circumcision.In arms B and C, the clinics initially provided ART at a CD4 threshold of 350 cells per microliter, however this increased to 500 cells per microliter in 2014 and universal ART was offered from 2016.After the introduction of universal ART, the two intervention arms were equivalent.
The effect of the intervention was measured in a population cohort (enrolled from December 2013 to March 2015) that included one randomly selected adult aged 18 to 44 years from a random sample of households in each community.Participants were surveyed at baseline and after 12, 24, and 36 months.The original enrolment target (2500 adults per community) was not reached at baseline, so additional participants were enrolled at 12 months and at 24 months, excluding households sampled previously.
At each survey, participants were interviewed by a field research assistant using a structured questionnaire that included the collection of demographic, socioeconomic, and behavioural data as well as data related to HIV and health-related quality-of-life.After the interview, blood was collected by a research nurse, who also offered rapid HIV testing to all participants.
The analysis presented here used cross-sectional data from the final survey, conducted 36 months after the start of the HPTN 071 (PopART) trial, between 8 th September 2017 and 7 th July 2018.
The sample size for the HPTN 071 (PopART) trial determined the sample size used in this analysis.Before the trial began, the sample size for HPTN 071 (PopART) was determined from initial projections of the intervention effect on HIV incidence from mathematical modelling, which indicated that around 2,500 participants were required per community.

S1b: Blood sample and HIV testing
Blood samples were analysed in-country using a single 4 th generation assay (Architect HIV Ag/Ab Combo Assay, Abbott Diagnostics, Delkenheim Germany).Further testing was performed at the HIV Prevention Trials Network (HPTN) Laboratory Center (Baltimore, MD, USA).Samples that had reactive results in-country were tested with a second 4 th generation assay (GS HIV Combo Assay, Bio-Rad Laboratories, Redmond, Wa).For quality assurance, 10% of the samples that had non-reactive results in-country were tested again using the Architect HIV Ag/Ab Combo Assay.Samples with discrepant/discordant test results were tested with additional assays to determine HIV status.

S1c: Stigma composite variables
The stigma composite variables were derived from 11 questions that people living with HIV were asked.For a woman living with HIV, aged 35-39 from the Dambwe community, who had reached secondary level of education, was in the poorest wealth quintile, was Christian, married, and had not taken recreational drugs in the last year, nor been told she has tuberculosis in the last year and… Had not experienced HIV stigma, the odds of reporting problems in at least one domain of HRQoL was 0.08.
Had experienced HIV stigma in healthcare settings at least once, the odds of reporting problems in at least one domain of HRQoL was 0.09.
Had experienced HIV stigma in the community at least once, the odds of reporting problems in at least one domain of HRQoL was 0.13.
Had experienced internalised stigma, the odds of reporting problems in at least one domain of HRQoL was 0.17.
The association between experiencing any HIV stigma and reporting problems in five dimensions of health-related quality-of-life among 3,991 people living with HIV from 21 study communities in South Africa and Zambia For a woman living with HIV aged 35-39 from the Dambwe community, who reached secondary level of education, was in the poorest wealth quintile, was Christian, married, and had not taken recreational drugs in the last year, nor been told she had tuberculosis in the last year… The odds of reporting problems in the domain of mobility were 0.008 for those who had not experienced HIV stigma, and 0.022 for those who had experienced HIV stigma at least once.
The odds of reporting problems in the domain of self-care were 0.004 for those who had not experienced HIV stigma, and 0.007 for those who had experienced HIV stigma at least once.
The odds of reporting problems in the domain of daily activities were 0.035 for those who had not experienced HIV stigma, and 0.047 for those who had experienced HIV stigma at least once.
The odds of reporting problems in the domain of pain were 0.047 for those who had not experienced HIV stigma, and 0.096 for those who had experienced HIV stigma at least once.
The odds of reporting problems in the domain of anxiety/depression were 0.033 for those who had not experienced HIV stigma, and 0.100 for those who had experienced HIV stigma at least once.

Table S1 Questions capturing the composite stigma outcomes Composite stigma variable Questions asked in the creation of composite variable
Please tell me how strongly you agree or disagree with the following statements:• I have lost respect or standing in the community because of my HIV status.•I think less of myself because of my HIV status.•I have felt ashamed because of my HIV status.